Adult Medicaid Admin. Letters
DMA ADMINISTRATIVE LETTER NO: 04-04, MEDICAID/NCHC PROCEDURES FOR HURRICANE ISABEL VICTIMS
DATE: SEPTEMBER 26, 2003
SUBJECT: Medicaid/NCHC Procedures for Hurricane Isabel Victims
DISTRIBUTION: COUNTY DIRECTORS OF SOCIAL SERVICES
This letter contains guidance on several Medicaid/North Carolina Health Choice for Children (NCHC) issues that the State anticipates as possible problems for the disaster counties due to interruptions in your normal business activity caused by Hurricane Isabel. Included are EIS instructions and policy guidance. As other situations are identified, we will provide further guidance as needed.
II. counties that requested extended certification periods
Due to disruptions caused by Hurricane Isabel, it has not been possible for some of the affected counties to complete all September redeterminations/re-enrollments. Disaster counties were given the option to have the certification periods of Medicaid and NCHC extended. Eight counties chose this option. Medicaid/NCHC cases in the following counties had benefits extended: Chowan, Gates, Halifax, Hertford, Hyde, Northampton, Perquimans, and Tyrrell.
A. Action Taken
On September 25, 2003 after the nightly update, EIS extended certification periods in the eight counties that requested the extension. For Medicaid cases, the certification period was extended for the month of October 2003. For NCHC cases, the certification period was extended for October 1, 2003 through September 30, 2004. Twelve months were authorized for NCHC to ensure the certification periods were kept in synch in the EIS and Blue Cross Blue Shield (BCBS) systems.
1. Cases extended included:
a. Open cases with certification periods ending September 30, 2003
b. Authorized medically needy cases
c. Long term care cases
d. CAP cases
e. MIC/NCHC cases that would normally have been automatically terminated on September 30, 2003
2. Cases that were not extended included:
a. Cases in deductible status
b. Medicaid for Pregnant Women
c. Transitional Medicaid cases
d. Cases already terminated in EIS effective September 30, 2003
e. MIC and NCHC cases that had only one individual on the case and that individual was age 19 on or before 9/30/2003
f. MIC with classification of “L”
B. On September 25, 2003 (PULL)
1. Cases with automated timely terminations pending in EIS due to process on or before September 25, 2003 terminated as usual.
2. EIS extended Medicaid cases with certification periods ending on September 30, 2003 for one month. The certification period will be October 1, 2003 through October 31, 2003 with an authorization date of October 1, 2003. (Example: Certification period was April 1, 2003 through September 30, 2003. EIS changed the certification period to October 1, 2003 through October 31, 2003.)
3. NCHC cases with classes of “J”, “K”, and “S” certification periods were extended to October 1, 2003 through September 30, 2004. Blue Cross Blue Shield’s system will not accept a one month extension.
4. An Individual Special Use code of I1 with a from and through date of 10 2003 was entered by EIS.
5. NCHC cases that had a classification of “J”,“K”, or “S” remained “J”, “K”, or “S” classification if automatically extended by EIS.
6. Cases with pending DSS-8125’s on hold due to errors, timely notice, awaiting supervisor approval, etc. were not updated or extended. You must process the form on these.
7. Automated transfers of AAF to MAF-C due to end of benefit diversion and 24 months of benefits occurred as usual.
C. Notices, Cards, and Reports
1. An automated adequate DSS-8110 notice is being mailed to recipients with extended certification periods. The notice states: DUE TO HURRICANE ISABEL, THE STATE EXTENDED YOUR MEDICAID BENEFITS FOR ONE MONTH, OCTOBER 2003.
2. The Medicaid cases extended on “pull night” do not already have ID cards printed. Therefore, October cards for the extended cases will be printed the night of October 1, 2003 and mailed on October 2, 2003. The Medicaid Straggler register for October 1, 2003 will list these cards.
3. NCHC recipients will receive a card with a certification period of October 1, 2003 through September 30, 2004. They will receive a laser printed notice informing them that their case has been extended for one month, October. (See D. below for instructions on keying reviews.) The notice states: DUE TO HURRICANE ISABEL, THE STATE EXTENDED YOUR NC HEALTH CHOICE BENEFITS FOR 1 MONTH. THE NC HEALTH CHOICE ID CARD WILL SAY YOU ARE COVERED FOR 1 YEAR. PLEASE UNDERSTAND COVERAGE IS ONLY FOR OCTOBER 2003.
4. A report of extended cases will be available in NCXPTR. The report name is “DHRWDB CASES EXTENDED BY ISABEL.” This report was available on September 26, 2003. The title of the report is Medicaid/NCHC Cases with Certification Periods Automatically Extended Due to Hurricane Isabel.
D. Reviews on Extended Cases
1. Medicaid Cases
a. If a case that was extended is to be terminated effective October 31, 2003 or another negative action (e.g. placed in deductible status) is to be effective November 1, 2003 and an adequate notice does not apply, the county must do a timely notice prior to these actions. If a previous manual timely notice was sent to be effective September 30, 2003 and the certification period was extended, a new timely notice is required, if still applicable.
b. At review, enter a new certification period beginning the next benefit month.
c. For medically needy cases, calculate a six month deductible and enter a new six month certification period.
Case was originally certified April 1, 2003 through September 30, 2003. EIS extended the certification period to October 1, 2003 through October 31, 2003. Enter a new certification in EIS for November 2003 through April 2004.
2. For NCHC Cases:
a. If the NCHC classification stays the same and there are no changes needed:
(1) Do not key anything into EIS, and
(2) Send the recipient an adequate DSS-8110 notice notifying him that he is eligible for the remaining 11 months in his certification period. (Remember his card showed 12 months but he received an automated notice telling him that he was certified for October only.)
b. If the NCHC classification stays the same and there are changes needed that do not affect eligibility:
(1) Key the changes, and
(2) Send the recipient an adequate DSS-8110 notice notifying him that he is eligible for the remaining 11 months in his certification period.
c. If the NCHC classification changes to “J”, “K”, or “S” when you conduct the review, you must:
(1) Terminate the existing NCHC case, and
(2) Enter a new application type 1 with the correct classification code and a certification period of November 1, 2003 through October 31, 2004.
(3) An automated approval notice will be sent to the client.
d. If the NCHC classification changes to “L” when you conduct the review, you must:
(1) Terminate the existing NCHC case,
(2) Enter a new application type 1 with the correct classification code and a certification period of November 1, 2003 through October 31, 2004,
(3) Enter disposition code B5,
(4) Override the automated notice,
(5) Send a manual adequate DSS-8110 notice informing the family, “Your child(ren) no longer qualifies for NC Health Choice for Children due to the income limit. You may opt to pay the full NCHC premium for coverage of the child(ren) for 12 months after loss of NCHC. You will receive additional information from the State Employee’s Health Plan,”
(6) Put the DSS-8125 on hold, and
(7) Call EIS at 919-857-4019. (Note: Have the form number ready when you call EIS.) EIS will have to process the form.
e. If the case is totally ineligible:
(1) Terminate the case, and
(2) Send the client an adequate DSS-8110 notice.
f. If the case is ineligible for NCHC, but eligible for Medicaid:
(1) Terminate the NCHC case effective October 31, 2003,
(2) Enter a reapplication for Medicaid and enter a 6/12 month certification period beginning November 1, 2003.
(3) An automated adequate DSS-8110 notice will be sent to the client.
3. Complete and key reviews on extended cases as soon as possible.
4. If recipients are unable to get to their own county DSS, another county can conduct a courtesy review. The county taking the courtesy review will need to contact the second county to find out to whom to send the review, do the interview, complete the review document to the extent possible, and collect information provided at the interview. Mark any courtesy review taken under these circumstances as “Isabel.” Immediately forward the information to the attention of the person designated by the second county.
III. Policy issues
This policy applies to the following counties: Beaufort, Bertie, Brunswick, Camden, Carteret, Chowan, Craven, Currituck, Dare, Edgecombe, Gates, Halifax, Hertford, Hyde, Jones, Martin, New Hanover, Northampton, Onslow, Pamlico, Pasquotank, Pender, Perquimans, Pitt, Tyrrell, and Washington.
A. Replacing ID Cards
1. Many Medicaid recipients may not be able to receive ID cards due to relocation or disruptions of mail service. If the recipient contacts you and states that he did not receive his Medicaid card in the mail due to relocation or disruptions in mail service, take the following action.
a. If the October ID card was returned to your office by the Post Office, give it to the recipient.
b. If the October ID card was not returned to you,
(1) Verify the recipient’s current eligibility in EIS.
(2) Confirm with the recipient his current address and, if different, change it in EIS.
(3) Issue a Medicaid ID replacement card with the pharmacy stub attached.
2. If the recipient that requests a replacement card is from another county, attempt to contact the recipient’s county to advise them of the request.
a. Verify the recipient’s eligibility in EIS.
b. Issue a Medicaid ID replacement card with the pharmacy stub attached.
c. Send a photocopy of the replacement card to the county of residence on your county’s letterhead and annotate it “Isabel”.
3. Counties will not be held responsible if the recipient receives more than 6 prescriptions in a month as a result of issuing a duplicate pharmacy stub.
4. If a pharmacist should contact you with concerns about exceeding the 6 prescriptions in a month or about not being the pharmacy on record, refer him to EDS Provider Services for instructions on what to do.
5. These procedures will remain in place through October. If extended, you will be advised in writing.
B. Re-enrollment Forms (MIC/NCHC)
1. Attempt to call the recipient if the automated re-enrollment form for NCHC or MIC has not been returned by the due date.
2. Use DMA-5063 and note “Re-enrollment” if the client requests a new re-enrollment form. Follow policy in F&C manual section MA-3420, Re-enrollment, IV. C. regarding mail-in re-enrollment forms not received by the recipient.
C. Unable to Locate
Due to the relocations caused by Hurricane Isabel, do not automatically terminate cases as unable to locate. You must:
1. Attempt to contact the client.
2. Check record for any contact phone numbers for family or friends.
3. Document the record listing all attempts to locate an address.
4. Send a timely notice to his last known address proposing termination for inability to locate.
Refer to instructions in MABD manual section MA-2352, Terminations/Deletions and F&C manual section MA-3410, Terminations and Deletions.
D. Unearned and Earned Income
These procedures apply to both applications and reviews.
1. Emergency/Disaster Funds
Refer to MABD manual section MA-2250, Income and F&C manual section MA-3300, Income.
a. Disaster assistance provided to victims of a presidential declared disaster is not counted as income. This includes assistance from:
(1) Federal programs and agencies,
(2) Joint federal and state,
(3) State or local government,
(4) Private organizations such as Red Cross, Salvation Army, etc.
b. Additionally, for an aged, blind, or disabled a/r in a presidential declared disaster county who is living in the household of another, in a shelter, or in a residence or other abode maintained by another individual, the value of in-kind support and maintenance does not count nor is the 1/3 reduction applied if:
(1) The a/r was subject to the full income limit prior to the hurricane (Refer to MABD manual section MA-2261, 1/3 Reduction, I.A.), and
(2) The a/r had to move because of the hurricane, and
(3) He began to receive the in-kind support and maintenance or began living in a situation where the 1/3 reduction would apply within 30 days after being forced to leave his home.
Follow policy in MABD manual section MA-2250, Income, IV.D.3. and F&C manual section MA-3300, Income, III.D.
a. For applications, applicant’s statement is acceptable as a last resort as verification of income, employment status, etc.
b. For reviews or changes in situation:
(1) Verify income for employment by pay stubs or wage letter unless the recipient states that employer’s or his records have been destroyed due to the hurricane.
(a) If the recipient states that his records have been destroyed, attempt to call the employer.
(b) If you are unable to reach the employer and no other verification is available, accept the recipient’s statement.
(2) If the recipient has stopped work because the business where he is employed is closed due to damage and it is uncertain when the business will reopen, treat as terminated income.
(a) Attempt to contact the employer to verify the status of the business.
(b) If you are unable to contact the employer, accept the recipient’s statement.
a. For self-employment, if the business is unable to operate due to the hurricane, treat as terminated income if uncertain as to when it may reopen.
(1) Accept the a/r’s statement that the business is unable to operate.
(2) Tell him to notify you within 10 calendar days if the business reopens.
b. For self-employment businesses that are operating but records have been damaged:
(1) Attempt to obtain verification from ledgers or records maintained for tax purposes, etc. if available.
(2) Attempt to call the business’ accountant for verification if applicable.
(3) Take client’s statement of earnings and deductions for operational expenses if records were destroyed due to Hurricane Isabel and there is no other means to verify.
(4) For deductions of operational expenses have applicant to state in writing what the deductions or operational expenses are and the amounts.
(5) For allowable operational expenses refer to MABD manual section MA-2250, Income and F&C manual section MA-3300, Income.
1. Insurance Payments
Follow policy in MABD manual section MA-2230, Financial Resources, X.C.8.c. to evaluate whether payments received for needed repairs are a non-countable resource.
a. Exclude money received for repairs for 9 months from the date of receipt.
b. Extend the exclusion for an additional 9 months when circumstances beyond the recipient’s control prevented the repair or contracting for the repair.
(1) Document the record the recipient still plans to use the money for repairs and the reason repairs have not been made.
(2) If this cannot be documented, count the remaining money in reserve after the first 9 months.
2. Federal Disaster Relief
Permanently exclude as resources payments received from federal Disaster Relief and Emergency Assistance Act of 1974 or some other Federal Statute because of a presidential declared major disaster.
F. Other Verifications
1. Medical Bills
Contact providers to verify medical bills if the recipient states his medical receipts were destroyed due to the Hurricane.
2. Pregnancy Verification
G. NC Health Choice for Children
NCHC a/r’s may need more than 10 days to pay the enrollment fee. Work with the applicant to give a reasonable extension based on circumstances and take advantage of local funding sources to pay fees on behalf of these families.
IV. Managed care
As stated above, this letter is an attempt to provide guidance for situations that we have identified as potential problems for counties affected by Hurricane Isabel. You may encounter situations that we have not identified, or variations on the situations identified in this letter that we did not anticipate. Should you encounter situations in which you need additional guidance, please contact the Medicaid Eligibility Unit at (919) 857-4019.
Gary H. Fuquay
(This material was researched and written by Debbie Pittard, Medicaid Eligibility Unit.)